Saturdays at FAME can often be a bit slower than weekdays and the staff is a bit lighter, but we’re open for the entire day to see patients. Things worked out rather well for us today and even though there were the same number of patients as we had on the prior two days, it was just that much more efficient so it looked like we would be finishing a bit early. The day was filled with mostly headaches, an essential tremor and Marissa had to deal with a full term 1.6 KG infant. Our little two-year-old child who was febrile and encephalopathic seemed to be doing a bit better and her fever curve seemed to be trending downward. We still recommended another lumbar puncture since the previous one done ten days or so ago had been totally bland. Her case remained a mystery and, though she was improving, she remained on multiple therapies which isn’t the most comfortable thing for us.
The big news of the day perhaps was the Hadza woman with the hemorrhage who we had scanned yesterday and admitted to the ward. At morning report, we learned that she had had another seizure and was now worse than she had been when we had last seen her. She was no longer very responsive and wasn’t really moving her right side as spontaneously as she had the day before. All this was very worrisome, though we didn’t have a very good feel about her to begin with. We sent her for a repeat head CT with contrast along with a CT of her chest and abdomen to look for any source of a hemorrhagic metastasis (we hadn’t seen a met and it was just in our differential, so we didn’t want to move her twice to CT scanner if it was needed. The chest and abdomen scans were unrevealing, but unfortunately, the head CT demonstrated further progression of her now clearly subarachnoid blood extending into her ventricular system including her fourth ventricle which was enlarged. She was quickly developing hydrocephalus and would very likely herniate and die if she didn’t have an EVD (extra-ventricular drain) placed which was something that we could not do here at FAME and she would have to be sent to either Arusha or KCMC (Kilimanjaro Christian Medical Center) to have that done.
The real problem was that she had suffered a devastating neurologic injury that, even with the EVD, she would not recover from in any sense to become independent or even a reasonable quality of life. She had already damaged her dominant hemisphere which made her aphasic and would very likely not be moving her right side again. Referring her to Arusha or to KCMC was clearly the wrong thing to do and everyone agreed that we should make her comfortable and allow her to pass in a dignified manner. This would absolutely need to be discussed with her family, which was the next step, and something that can often be difficult through translators. I recall a number of years ago when I had to tell a young Maasai mother that her eleven-year-old son who I had just diagnosed with muscular dystrophy would very likely not grow up to be a Maasai warrior. Using a Maasai interpreter, I had carefully and compassionately chosen my words and allowed her plenty of opportunity to ask me questions along the way and she did have some. She listened with what had seemed almost like a detached affect and I had thought to myself how different we were culturally, but the in the end we were both parents of children who only wanted the best for them – to grow up healthy and suffer no pain. She had remained stoic and emotionless for what seemed for such a long time, but then suddenly broke down in tears and it was very clear to me at that moment, as it always has been throughout my life, that we were of the very same cloth despite whatever outward differences were obvious. Looking into her face was as if I were looking into a mirror.
Our Hadza patient was from a dying tribe, a group of ancient and anthropologically very distinct people that represent the last of the hunter gatherers in Tanzania, still speak click language, hunt with bows and arrows, and are most closely related to the bushman of Southern Africa. They number perhaps 1500 individuals and live in the Lake Eyasi region where they are being slowly displaced due to the loss of their game. They are now left to hunt dik dik (the smallest of antelopes in Africa) and baboons for subsistence. Their large game is now gone and other tribes have begun grazing cattle on their land. Our patient was a member of this unique group of people who will very likely not survive the coming decades and she was brought here for us to treat only to find that the best option was to let her die in peace. She wasn’t the last of her tribe, but she certainly could have been. Her daughter, who was the only member of her family who had traveled with her, remained at her bedside.
Dr. Badyana accompanied both Mike and I to speak with the daughter as we had already spoken with Dr. Frank who had agreed wholeheartedly with our plan as had Daudi Peterson who has sent her to us in the first place. Knowing that the daughter, who was alone here in Karatu, could be easily overwhelmed, I sat next to her on a small seat and began to explain to her what had happened to her mother and why she was getting worse. I showed her images on my phone from the CT scan that I’m fairly certain she understood as I would have expected any family in the US to understand. It wasn’t a medical lesson, but merely a means of demonstrating to her that something very bad had happened to her mother and that regardless of what we did, she likely not going to survive nor recover in any meaningful fashion. Badyana did an excellent job of interpreting this rather complex set of circumstances. She had few questions, but made it clear that she didn’t feel comfortable making decisions without knowing that Daudi was aware of things and we told her that he was, but that I would also try to reach him if I could. As with the Maasai mother several years ago, I could have been having this same conversation with a patient’s family in the US. Despite her ancient heritage and the differences between our worlds, I was very comfortable that she understood the gravity of the situation and the fact that her mother was going to die. I consider these moments one of the greatest honors in practicing medicine, to help a patient or family through this process.
Meanwhile, on the complete opposite end to spectrum, I went with Marissa to the nursery to evaluate the little 1.6 Kg full-term baby who had come in the night before. Her mother had gone to KLH (Karatu Lutheran Hospital, the local government hospital in Karatu) in labor and with polyhydramnios. She had a C-section there and the baby was immediately sent to us, while the mother remained at KLH as she was post-op from her section. The baby looked wonderful and seemed to be completely intact neurologically which was obviously a very good thing. She was tiny and was receiving IV fluids, was urinating, but hadn’t had a stool yet. Of course, I am of very little help in these situations, working next to pediatrician, but I stayed for moral support as Marissa did her complete assessment and made her recommendations. I am merely a facilitator here and can help answer questions or offer common sense, but anything more specific than that came directly from Marissa. We would continue to follow the baby here and were looking forward to the mother arriving to feed her and to see exactly how she was functioning at that point. As we were heading to Lake Manyara on Sunday, we wanted to make sure that everything was doing well and would evaluate her again on Monday.
We were finished in clinic and it was market day in Karatu, so we decided that I would drop the group off in the market and then we would head up to Gibb’s Farm for drinks and to watch the sunset. Every town with a Maasai population has a market day usually two times a month in which all the Maasai from the surrounding bomas will come to town to sell their livestock and other wares. There are also lots of others selling things at the market and, most notable, those selling used clothing that arrives in huge 4x4x6 foot bales, or thereabouts, that are bound tightly and have been shipped primarily from the US. They are comprised of donated clothing and it is not uncommon see a T-shirt with the losing team as the champion as they are all shipped here after the game. I’ve mentioned a wonderful book before, The Blue Sweater, in which the title comes from this practice of selling donated clothing in Africa, but the book itself is about how one individual can realize their dreams and change people’s lives, though, unfortunately, as is often the case, politics get in the way to nearly unravel all the good that is done. It takes place in Rwanda so it takes very little imagination to understand the consequences that take place in the book. It is well worth reading and I highly recommend it.
I dropped the group off at the Maasai Market, which is a sea of humanity selling everything under the sun, literally. My only instruction to them was not to buy any livestock, but everything else was fair game. I was heading into town to buy groceries for our house and our safari the following day. I told them I’d be back in an hour to pick them up at the same spot I dropped them off. I received a text from Marissa in probably 30 minutes that they were done and needed to be rescued. This was not surprising as the market is incredibly overwhelming and claustrophobic while the entire time you’re being followed and hounded by individuals trying to sell you something. Telling them “no” is not always sufficient and it can be very, very intimidating to say the least. I wanted them to experience it, but was not surprised with the quick rescue call and I quickly finished my shopping and drove back to the fairgrounds where my group looked a bit harried, but still together and smiling. No one had bought a thing as they hadn’t wanted to open the flood gates.
We drove home from the market to change and then head up for a relaxing evening at Gibb’s Farm. The back road that I take to Gibb’s can be a bit intimidating for those uninitiated, but it saves time and, besides, it a blast for me to drive. As long as it hasn’t rained, in which the entire road becomes a slip and slide event, I always enjoy driving this short cut. Despite their fears, we made it to Gibb’s in one piece to enjoy the amazing scenery of this world-class resort that ranks in the very top echelon of five-star destination resorts. I have one resident, who upon visiting Gibb’s, decided that she was going to get married there (you know who you are) and another who is planning to renew her wedding vows at some point in the future. (you also know who you are). It is that beautiful and spellbinding and it never fails to take everyone’s breath away with every visit. We found Margaret and Reema, the two anesthesiologists from UCSD, still there from their earlier lunch that day and an empty table on the veranda for all of us to sit and watch the sunset. It was incredibly relaxing and worth every minute as we sat until long after sunset enjoying our drinks and just sharing stories. I drove Reema and Margaret home so they wouldn’t have to get a taxi and, yes, I took the same exciting short cut just for effect. We made it home with plenty of time for Marissa to cook dinner (we hadn’t eaten yet) and to prepare lunch for the following day at Lake Manyara. I had very little to do as the residents and Leah had pretty much taken care of everything by the time I turned around. We were planning to leave before sunrise, so everyone made it to bed early with thoughts of all the wild animals that we’d see tomorrow.